SUMMARYThe Madden-Julian Oscillation (MJO) is the dominant mode of tropical variability at intraseasonal timescales. It displays substantial interannual variability in intensity which may have important implications for the predictability of the coupled system. The reasons for this interannual variability are not understood. The aim of this paper is to investigate whether the interannual behaviour of the MJO is related to tropical sea surface temperature (SST) anomalies, particularly El Niiio, and hence whether it is predictable.The interannual behaviour of the MJO has been diagnosed initially in the 40-year National Centers for Environmental PredictiodNational Center for Atmospheric Research (NCEPNCAR) Reanalysis. The results suggest that prior to the mid-1970s the activity of the MJO was consistently lower than during the latter part of the record. This may be related either to inadequacies in the data coverage, particularly over the tropical Indian Ocean prior to the introduction of satellite observations, or to the real effects of a decadal time-scale warming in the tropical SSTs. The teleconnection patterns between interannual variations in MJO activity and SST show only a weak, barely significant, influence of El Niiio in which the MJO is more active during the cold phase.As well as the NCEPNCAR Reanalysis, a 4-member ensemble of 45-year integrations with the Hadley Centre climate model (HadAM2a), forced by observed SSTs for 1949-93, has been used to investigate the relationship between MJO activity and SST. HadAM2a is known to give a reasonable simulation of the MJO, and the extended record provided by this ensemble of integrations allows a more robust investigation of the predictability of MJO activity than was possible with the 40-year NCEPNCAR Reanalysis. The results have shown that, for the uncoupled system, with the atmosphere being driven by imposed SSTs, there is no reproducibility of the activity of the MJO from year-to-year. The interannual behaviour of the MJO is not controlled by the phase of El Niiio and would appear to be mainly chaotic in character. However, the model results have confirmed the low-frequency, decadal time-scale variability of MJO activity seen in the NCEPNCAR Reanalysis. The activity of the MJO is consistently lower in all realizations prior to the mid-1970s. suggesting that the MJO may become more active as tropical SSTs increase. This result may have implications for the effects of global warming on the coupled tropical atmosphere-ocean system.Since the observed and simulated MJOs display clear seasonality in their occurrence, the relationship with interannual changes in the mean seasonal cycle of the tropical circulation has also been investigated. In contrast to the MJO, the interannual variability in the mean seasonal cycle is reproducible and influenced by the phase of El Niiio. The implications of these results for the predictability of the tropical atmosphere-ocean system are discussed, particularly with reference to the strong El Niiio event of 1997 which developed i...

The objective of this study was to review the literature for malignant melanoma, basal and squamous cell carcinomas to understand: (a) national estimates of the direct health system costs of skin cancer and (b) the cost-effectiveness of interventions for skin cancer prevention or early detection. A systematic review was performed using Medline, Cochrane Library and the National Health Service Economic Evaluation Databases as well as a manual search of reference lists to identify relevant studies up to 31 August 2013. A narrative synthesis approach was used to summarize the data. National cost estimates were adjusted for country-specific inflation and presented in 2013 euros. The CHEERS statement was used to assess the quality of the economic evaluation studies. Sixteen studies reporting national estimates of skin cancer costs and 11 cost-effectiveness studies on skin cancer prevention or early detection were identified. Relative to the size of their respective populations, the annual direct health system costs for skin cancer were highest for Australia, New Zealand, Sweden and Denmark (2013 euros). Skin cancer prevention initiatives are highly cost-effective and may also be cost-saving. Melanoma early detection programmes aimed at high-risk individuals may also be cost-effective; however, updated analyses are needed. There is a significant cost burden of skin cancer for many countries and health expenditure for this disease will grow as incidence increases. Public investment in skin cancer prevention and early detection programmes show strong potential for health and economic benefits.

WITH TWO PLATES SummaryScanning electron micrographs show that the reaction products of solution phosphate and calcite are hemispherical, coral-like growths on calcite surfaces. Electron probe micro-analysis indicates that these are a calcium phosphate, and solution data plotted against solubility isotherms suggest that dicalcium phosphate (DCP) is formed rapidly and slowly changes to octa-calcium phosphate (OCP). X-ray diffraction shows that DCP and OCP are present with DCP predominating. The ratio of Ca:P in the treated calcite, after allowing for the CaC03 present, is that in DCP. and a surface coating of OCP on DCP is likely. The exchangeability of the reacted P falls from 100 per cent for small amounts (0-10 pg P per g calcite) to a constant 30 per cent when larger amounts are present (200-1000 p d g ) resulting from the porous structure of the coral-like growths. These cover only a small fraction of the calcite surface even when large amounts of P are present so allowing calcite to control solution pH. IntroductionTHE reaction of phosphate with calcite surfaces involves adsorption of small amounts of phosphate followed by precipitation of calcium phosphate at higher levels (Cole et al., 1953). The adsorption has been described by the Langmuir isotherm (Kuo and Lotse, 1972), with better fit when the isotherm is divided into two linear sections (Griffin and Jurinak, 1973) and has been described as a heterogeneous nucleation process leading to about 5 per cent of the calcite surface being covered with phosphate.The initial adsorption is thought to occur at certain sites where lateral interaction between phosphate ions produces surface clusters which then act as nuclei for subsequent crystal growth. These nuclei are presumably an amorphous calcium phosphate (Stumm and Leckie, 1970) which is slowly transformed into crystalline calcium phosphate, the form of which seems to depend on the adsorbing surface and on the solution conditions. For example Cole et al. (1 953) found evidence that dicalcium phosphate was formed, Clark and Peech (1955) concluded that octacalcium phosphate or dicalcium phosphate were formed depending on the conditions, Stumm and Leckie (1 970) showed that apatite formed in calcareous sediments, and Holford and Mattingly (1975) found octacalcium phosphate in soils on Oolitic Limestone. Time of reaction is also likely to be important, for Arvieu and Bouvier (1974) state that dicalcium phosphate is the first reaction product which by hydrolysis gives octacalcium phosphate, and

Patient safety efforts frequently focus on dramatic but rare complications with very serious patient harm. Previous studies of the costs of adverse events have provided information on 'indicators' of safety problems rather than the full range of hospital-acquired conditions. Adding a cost dimension to priority-setting could result in changes to the focus of patient safety programmes and research. Financial information should be combined with information on patient outcomes to allow for cost-utility evaluation of future interventions.

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